A 35 year old female known to suffer with severe depression and suicidal tendencies goes missing from her home address. Search teams are deployed and following a 3 day search the missing person is found alive but very cold and in a remote area of woodland inaccessible to other emergency services. Further medical support is requested to aid with rewarming the MISPER (missing person) and evacuate her to hospital.
Should adult patients be routinely discharged with Naspetin cream after primary epistaxis?
A 44 year old male presents to the ED with primary epistaxis. It has spontaneously resolved. Should Naseptin cream be given on discharge to prevent recurrence?
A 68-year-old female presents to your emergency department with chest pain and dyspnea. Her ECG reveals sinus tachycardia and slight ST elevation in leads I and aVF with reciprocal ST depression in leads I and aVL. Before activating the cardiac catheterization laboratory, you consider the other causes of ST-segment elevation.
An 80 year old man with a history of atrial fibrillation on warfarin presents to the emergency department after a ground level fall. He reports hitting his head, but denies loss of consciousness. Vital signs are stable and within normal limits at presentation, GSC is 14. Physical exam is unremarkable. Initial head CT scan is read as negative for acute abnormality without evidence of intracranial hemorrhage. Can the patient safely be discharged home?
An adult patient presents to the emergency department with acute renal colic ('loin-to-groin' pain). You would like to give Tamsulosin 'off-label' to facilitate stone passage.
Clinical features distinguishing apical ballooning syndrome from anterior st-elevation MI
A 69 year old woman presents to the emergency department patient with acute onset of chest pain and dyspnea. Symptoms began while she was attending her son’s funeral service. Her electrocardiogram shows characteristic ST-segment elevation over the anterior precordial leads with a small elevation in troponin T. While paging the cardiologist, you wonder is this patient has a myocardial infarction or stress induced cardiomyopathy (apical ballooning syndrome or Takotsubo cardiomyopathy).
nX-Ray versus CT to confirm diagnosis of triplane fracture n
A 12 year old girl who has been brought with inversion injury to the left ankle while playing football. She was unable to bear weight. On examination there was swelling and tenderness over the lateral malleolus and anterior joint line. Left ankle X-ray showed Salter Harris Type 3 fracture of the distal tibia. You discussed with the orthopedic Specialty registrar on call; who was very kind to accept the patient and requested to carry out CT scan of the left ankle in order to rule out Triplane fracture. You wonder what is the sensitivity and specificity of x-ray to rule out Triplane fractures against CT scan being the gold standard.
How many supraglottic airway insertions are needed to gain initial competence?
You are training a number of prehospital care providers airway management skills. You want to know how many times they will need to insert a supraglottic airway device before gaining competence in this skill.
A 4-year-old boy presents in A&E with sudden onset facial paralysis and hemiplegia. CT scan followed by MR angiogram diagnose stroke as a result of thrombosis to Middle Cerebral Artery (MCA). The GP trainee who has worked in Medicine has seen thrombolysis being used in adult patients with stroke. He wonders whether thrombolysis should be carried out for this child.
Ibuprofen in the prevention of headache associated with acute mountain sickness.
A 32 year old patient reports having a persistent headache during his most recent mountaineering trip to Colorado. He notes the headache occurred just prior to reaching the summit of Pikes Peak (14,115 ft)and persisted until his decent. He wants to know if there are any safe and effective medications he can take to help alleviate his symptoms during future high altitude climbs.
A 30 year-old male is brought in by paramedics with ongoing generalised tonic/clonic seizures that have been ongoing for 25 minutes. The paramedics have given 15mg of Midazalam IM with no effect, and couldn't gain IV access due to extensive track marks over the patient’s veins from extensive IV drug use. Vascular access is urgently needed to terminate this state of status epilepticus and to prevent further neurological sequelae. A central line would take too long to place, and would be extremely difficult in this patient. You decide to use an IO access kit to gain rapid access in this patient, so that benzodiazepines can be administered.
Will continuous positive airway pressure reduce the need for ventilation in bronchiolitis?
You are asked to see a 2-month-old boy who has been ill for 3 days. He has respiratory syncytial virus positive bronchiolitis and is needing 1.5 L/min oxygen by low flow. His capillary blood gas has pH 7.26 pCO2 9.9 kPa pO2 4.5 kPa and base excess −5.0. His respiratory rate is 60 and increasing. The family has been told he may need moving to 40 miles to the regional paediatric intensive care unit (PICU). They are worried and angry, not least because his sister is delivering a baby upstairs. You wonder whether starting continuous positive airway pressure (CPAP) will reduce the need for ventilation and help keep them together.
Inhaled mannitol improves lung function in patients with cystic fibrosis
As the paediatric registrar in clinic, you see a child with cystic fibrosis (CF). Her mother mentions reading about newer treatments available to help improve lung function and mucus clearance. You have heard of inhaled mannitol being used in this context and wonder how effective it is and how it compares to the established treatments.
Is methylphenidate a useful treatment for cancer-related fatigue in children?
A 9-year-old boy with a brain tumour attends my outpatient clinic for review. His current most disabling symptom is fatigue. His parents have done a Google search and found that methylphenidate can be used to treat fatigue in adults. They ask my opinion as to whether this would be an option for their son. What should I advise?
A 3-year-old boy was seen in the community paediatric clinic for follow up of his Duchenne muscular dystrophy (DMD). There have been recent discussions about starting him on steroids. His parents would like to know if treatment with glucocorticoid corticosteroids (GCs) has been shown to prolong ambulation and the best age to start steroids. They also want to know if steroids reduce the complications of DMD and if the side effects of long-term steroids are acceptable.
A 50-year-old man attends the emergency department with a history of cough, shortness of breath and purulent sputum production. He is hypoxic and shocked. He requires intubation and ventilation, and his post-intubation chest X-ray is consistent with bronchopneumonia. Following appropriate fluid resuscitation, he remains hypotensive and norepinephrine is commenced. Despite rapidly escalating norepinephrine, additional fluids and corticosteroids (for their catecholamine sparing effect), he remains shocked. A bedside transthoracic echocardiogram demonstrates left ventricular dysfunction which you feel may be attributed to septic myocardial depression. You wonder whether he might benefit from the addition of levosimendan.
Bedside ultrasound for the diagnosis of necrotizing fasciitis
A 54-year-old man attends the emergency department complaining of a rapidly progressive pain and swelling in his right arm. He is mildly tachypnoeic and tachycardic. His arm is very tender and painful even at rest but is only slightly erythematous. He can move his hand, wrist and elbow with complete range of motion. You suspect a necrotising fasciitis. You wonder whether an ultrasound of the soft tissue night help to differentiate between cellulitis and a necrotising fasciitis.